FAMILY MEDICINE - CHRONIC DISEASE + LIFE-COURSE INTEGRATION

YEAR 3 | PAGE 31G - CONTROL -> COMPLICATIONS -> MEDICATION SAFETY -> GOALS ->

FOLLOW-UP — CONTINUITY CHANGES THE QUESTION

Family medicine repeatedly asks what to do after the diagnosis is already known. The answer may be to confirm control, detect complications, simplify medications, improve adherence, counsel behavior change, address cost/access, coordinate referrals or choose the correct follow-up interval. A good plan is measurable and sustainable.

E. CHRONIC-DISEASE CONTROL - USE THE SAME FIVE QUESTIONS

Condition	Control / complication questions	Management logic
Hypertension	Was the diagnosis confirmed appropriately? Current BP pattern, adherence, secondary causes, renal/CV disease, medication effects?	Separate routine chronic control from hypertensive emergency; choose therapy around comorbidity, pregnancy potential, renal function and adverse effects.
Diabetes	A1c/glucose trend, hypoglycemia, kidney/eye/neuropathy risk, BP/lipids, medications, nutrition/activity and access.	Management is more than glucose: reduce cardiovascular/renal risk, screen complications and tailor therapy to patient factors.
Lipids / ASCVD risk	Known ASCVD, LDL pattern, diabetes, age/risk, smoking/BP, statin tolerance and adherence.	Know primary vs secondary prevention logic and when risk/conditions change treatment intensity.
Asthma / COPD	Symptom frequency, exacerbations, inhaler technique/adherence, smoking/exposure, spirometry context, steroid burden.	Distinguish baseline controller adjustment from acute exacerbation treatment; technique and trigger reduction matter.
CKD	eGFR/albuminuria trend, BP/diabetes control, medication dosing, potassium/volume status, nephrotoxin exposure.	Protect kidney function, dose safely and recognize when progression/complications justify nephrology input.
Obesity / metabolic health	Trajectory, sleep, medications, nutrition/activity, complications, readiness, barriers and patient goals.	Use non-stigmatizing, longitudinal care; combine behavioral, pharmacologic or procedural strategies when indicated rather than one-off advice.
Depression / anxiety / substance use	Severity, function, suicide risk when indicated, response/adverse effects, adherence, therapy access, substance pattern.	Primary care owns longitudinal behavioral health: safety first, then evidence-based treatment, follow-up and escalation when needed.

F. LIFE-COURSE + WHOLE-PERSON INTEGRATION

Lane	What to integrate	Exam / clinic anchor
Women / reproductive care	Contraception, pregnancy intention, STI risk, abnormal bleeding, menopause, breast/cervical prevention and pregnancy overlap.	Do not silo reproductive health away from medications, chronic disease and prevention.
Pediatrics / adolescents	Growth/development, vaccines, common infections, asthma, school/behavior, safety, confidential adolescent care.	COMAT Family Medicine explicitly includes pediatric patients; adjust vitals, doses, risk and prevention by age.
Older adults	Function, falls, cognition, sensory loss, goals, frailty, caregiver burden and medication burden.	Deprescribing, function and goals can be more important than adding another disease-specific drug.
Social context / access	Cost, transportation, food/housing insecurity, work, caregiving, language, health literacy and trust.	A medically correct plan that cannot be obtained or followed is not a complete outpatient plan.
Medication / quality safety Ninja Nerd - Antihypertensive Drugs Ninja Nerd - Diabetes Mellitus \| Clinical Medicine Ninja Nerd - Asthma \| Clinical Medicine 2026/27 clerkship-expanded edition - verify school and official exam updates before testing	Reconciliation, interactions, renal/hepatic dosing, monitoring, refill adherence, diagnostic follow-up and referrals.	Close the loop on abnormal results and referrals; continuity creates responsibility for follow-through.